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Effectiveness and safety of endoscopic thoracic sympathectomy for excessive sweating and facial blushing: A systematic review

Published online by Cambridge University Press:  18 January 2007

Antti Malmivaara ,
Pekka Kuukasjärvi ,
Ilona Autti-Ramo ,
Niina Kovanen  and
Marjukka Mäkelä
Antti Malmivaara
Affiliation:
University of OuluandFinnish Office for Health Technology Assessment
Pekka Kuukasjärvi
Affiliation:
Finnish Office for Health Technology Assessment
Ilona Autti-Ramo
Affiliation:
University of HelsinkiandFinnish Office for Health Technology Assessment
Niina Kovanen
Affiliation:
University of HelsinkiandFinnish Office for Health Technology Assessment
Marjukka Mäkelä
Affiliation:
University of CopenhagenandFinnish Office for Health Technology Assessment
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Abstract

Objectives: Despite controversies, endoscopic thoracic sympathectomy (ETS) has been used as a treatment for excessive sweating of hands and face and for facial blushing. This study aims to evaluate the effectiveness of ETS for the current indications in a systematic review.

Methods: Controlled clinical trials and cohort studies with more than 100 patients were included. Abstracts were searched from MEDLINE and CCTR from 1966 to June 2004. Two reviewers extracted the data and assessed study quality. Data on effectiveness and safety were synthesized qualitatively.

Results: We did not find any controlled clinical trials. Fifteen prospective studies were included. The internal and external quality of these studies were poor overall. Follow-up was commonly less than 2 years, during which time excessive sweating and facial blushing seemed to decrease among most patients. Immediate complications related to thoracoscopy occurred in up to 10 percent of patients. Compensatory sweating below breast level was reported in up to 90 percent of the patients. Other common side effects included dryness of face and hands, gustatory sweating, and neuralgic pain. Several other less common side effects were reported.

Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.

Keywords

HyperhidrosisBlushingSympathectomyEffectivenessSafety
Type
GENERAL ESSAYS
Information
International Journal of Technology Assessment in Health Care , Volume 23 , Issue 1 , January 2007 , pp. 54 - 62
Copyright
© 2007 Cambridge University Press

Endoscopic thoracic sympathectomy (ETS) has been used for years to reduce excessive sweating in face and hands and blushing of the face due to overactivity of sympathetic nerves. In this procedure, the upper thoracic chain of the sympathetic nerve trunk is transected or clamped.

As no previous systematic reviews were identified, we set out to assess the effectiveness and safety of ETS. The results are reported previously in Finnish in a Finohta report (11).

METHODS

Randomized controlled trials, and prospective observational studies (at least 100 patients) on ETS were searched without language restriction in Medline (1966–July 2004) and in the Cochrane Library (2nd Quarter 2004). The Medical Section Heading (MeSH) search terms used were hyperhidrosis, sweating, or blushing. We included papers reporting at least one outcome measure of symptoms among patients with facial blushing or sweating in the face, hands, or elsewhere (trunk or feet).

Two researchers (A.M. and I.A.R.) selected together the full text articles based on titles and abstracts of the articles identified in the literature search. At least two researchers did the data extraction (A.M. and N.K. all the papers, I.A.R. half of the papers). Among the 195 retrieved articles, there were no trials. Fifteen prospective studies were included. Two studies focused on endoscopic thoracic sympathectomy for social phobia; these papers were not included in the present study. Two researchers (A.M. and P.K.) independently assessed the quality of the studies and the description of clinically relevant patient characteristics.

RESULTS

The methodological quality was poor in most studies (Table 1). Few clinically relevant patient characteristics were reported (Table 2). None of the studies provided clear inclusion and exclusion criteria for patients.

Description of patients, follow-up time, indication, and intervention is provided in Table 3. The fifteen studies had recruited 5,767 patients (mean, 384; range, 100–1,312), of which 46 percent were male (range, 26–56 percent). Patients were typically young adults (mean age, 21 to 34 years; age range, 5 to 72 years). Eight studies had included children less than 15 years of age. Five studies had uniform follow-up time for all patients. In three studies, the mean follow-up time was over 2 years, and only one had followed up all patients at least for 2 years (4).

Blushing and excessive sweating of hands, trunk, and feet decreased after ETS in all studies. In the absence of common objective outcome measures, the results cannot be combined.

Complications after ETS included hemo- or pneumothorax, Horner's syndrome, and neuralgias (Table 4). Some complications caused permanent disability. In all but two studies compensatory sweating after ETS occurred in more than half of the patients, typically on the trunk below the nipples. Of those who experienced hyperhidrosis, 3 to 15 percent considered it to cause significant disability. Excessive dryness of skin and gustatory sweating were also reported.

Patients had given written informed consent to the operation in two studies and oral consent in two others. No paper mentioned approval of the study by an ethical committee or informed about authors' conflict of interest.

DISCUSSION

The effectiveness of ETS in alleviating sweating or facial blushing cannot be evaluated on the basis of studies without control groups. Prospective patient series, however, can provide valid information of side effects of interventions. The studies of this review were seemingly prospective, although very variable follow-up times and other inconsistencies point toward the possibility of retrospective designs.

Endoscopic thoracic sympathectomy is associated with significant immediate and long-term adverse effects. Due to wide variation in the reporting of adverse effects, it is probable that these have been underreported most of the time.

If this procedure is considered safe enough for use, its effectiveness should be evaluated in prospective, controlled trials. Follow-up times should be sufficiently long to inform about possible recurrence of the symptoms. Informed consent for these studies and the ETS operations should be required, especially if minors are subjected to the risk of permanent complications.

CONCLUSIONS

No randomized trial has assessed the effectiveness of ETS. ETS is associated with significant immediate and long-term adverse effects. Compensatory hyperhidrosis after ETS is common and causes marked discomfort or disability in some patients.

POLICY IMPLICATIONS

The results may be used in discussions about the role and necessity of these operations in health care, and they can form a basis for patient information.

CONTACT INFORMATION

Antti Malmivaara, MD, PhD (), Adjunct Professor, Department of Physiatrics, University of Oulu, P.O. Box 8000, 90014 University of Oulu, Finland; Senior Medical Officer, Finnish Office for Health Technology Assessment (FinOHTA), National Research and Development Centre for Welfare and Health, P.O.Box 220, Lintulahdenkuja 4, FIN-00530 Helsinki, Finland

Pekka Kuukasjärvi, MD, PhD (), Senior Medical Director, Finnish Office for Health Technology Assessment (FinOHTA), Stakes, P.O. Box 220, FIN-00531 Helsinki, Finland

Ilona Autti-Rämö, MD, PhD (), Adjunct Professor, Deaprtment of Pediatrics, University of Helsinki, P.O. Box 280, 00029 HYKS, Finland; Senior Medical Officer, Finnish Office for Health Technology Assessment (FinOHTA), National Research and Development Centre for Welfare and Health, P.O. Box 220, Lintulahdenkuja 4, FIN-00530 Helsinki, Finland

Niina Kovanen, RN, MSc (), Development Manager, Finnish Office for Health Technology Assessment (FinOHTA), Stakes, P.O. Box 220, FIN-00531, Helsinki, Finland

Marjukka Mäkelä, MD, PhD, MSc (), Professor, Department of General Practice, University of Copenhagen, P.O. Box 2099, 1014 Copenhagen, Denmark; Research Professor, Finnish Office for Health Technology Assessment (FinOHTA), National Research and Development Centre for Welfare and Health, P. O. Box 220, Lintulahdenkuja 4, FIN-00530 Helsinki, Finland

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Figure 0

Quality of the Studies on Endoscopic Thoracic Sympathectomy

Figure 1

Successfulness of Reporting the Aims, Patient Selection, Inclusion and Exclusion Criteria, and Symptoms of Patients in the Studies on Endoscopic Thoracic Sympathectomy

Figure 2

Description of Patients, Follow-up Time, Indication, and Intervention

Figure 3

Description of Immediate Adverse Effects and Compensatory Excessive Sweating in Studies on Endoscopic Thoracic Sympathectomy